Department of Veterans Affairs Office of Inspector General Office of Healthcare Inspections Report No. 08-00819-143 Combined Assessment Program Review of the VA Salt Lake City Health Care System Salt Lake City, Utah June 10, 2008 Washington, DC 20420 Why We Did This Review Combined Assessment Program (CAP) reviews are part of the Office of Inspector General's (OIG's) efforts to ensure that high quality health care is provided to our Nation's veterans. CAP reviews combine the knowledge and skills of the OIG's Offices of Healthcare Inspections and Investigations to provide collaborative assessments of VA medical facilities on a cyclical basis. The purposes of CAP reviews are to: • Evaluate how well VA facilities are accomplishing their missions of providing veterans convenient access to high quality medical services. • Provide fraud and integrity awareness training to increase employee understanding of the potential for program fraud and the requirement to refer suspected criminal activity to the OIG. In addition to this typical coverage, CAP reviews may examine issues or allegations referred by VA employees, patients, Members of Congress, or others. To Report Suspected Wrongdoing in VA Programs and Operations Call the OIG Hotline – (800) 488-8244 Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, UT Table of Contents Page Executive Summary ................................................................................................... i Introduction ................................................................................................................ 1 Profile...................................................................................................................... 1 Objectives and Scope ............................................................................................. 2 Organizational Strength............................................................................................. 3 Results ........................................................................................................................ 4 Review Activities With Recommendations .............................................................. 4 Quality Management ......................................................................................... 4 Business Rules for Veterans Health Information Systems ................................ 5 Review Activities Without Recommendations ......................................................... 6 Environment of Care.......................................................................................... 6 Pharmacy Operations........................................................................................ 7 Survey of Healthcare Experiences of Patients .................................................. 8 Appendixes A. VISN Director Comments .................................................................................. 11 B. System Director Comments............................................................................... 12 C. OIG Contact and Staff Acknowledgments ......................................................... 13 D. Report Distribution............................................................................................. 14 VA Office of Inspector General Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, UT Executive Summary Introduction During the week of March 24–28, 2008, the OIG conducted a Combined Assessment Program (CAP) review of the VA Salt Lake City Health Care System (the system), Salt Lake City, UT. The purpose of the review was to evaluate selected operations, focusing on patient care administration and quality management (QM). During the review, we also provided fraud and integrity awareness training to 234 system employees. The system is part of Veterans Integrated Service Network (VISN) 19. Results of the The CAP review covered five operational activities. We identified the following organizational strength and reported Review accomplishment: • Electronic Morning Report. We made recommendations in two of the activities reviewed. For these activities, the system needed to: • Ensure that processing times for root cause analyses (RCAs) are improved. • Ensure that all clinically active staff have current cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) training, as required by Veterans Health Administration (VHA) and local policy. • Require that computerized patient record system business rules are in compliance with VHA policy and Office of Information (OI) guidance. The system complied with selected standards in the following three activities: • Environment of Care (EOC). • Pharmacy Operations. • Survey of Healthcare Experiences of Patients (SHEP). This report was prepared under the direction of Linda G. DeLong, Director, and Karen Moore, Associate Director, Dallas Office of Healthcare Inspections. VA Office of Inspector General i Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, UT Comments The VISN and System Directors agreed with the CAP review findings and recommendations and provided acceptable improvement plans. (See Appendixes A and B, pages 11–12, for the full text of the Directors’ comments.) We will follow up on the planned actions until they are completed. (original signed by:) JOHN D. DAIGH, JR., M.D. Assistant Inspector General for Healthcare Inspections VA Office of Inspector General ii Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, UT Introduction Profile Organization. The system is a tertiary care facility located in Salt Lake City, UT, that provides a broad range of inpatient and outpatient health care services. Outpatient care is also provided at eight community based outpatient clinics located in Ogden, Orem, St. George, Roosevelt, Nephi, and Fountain Green, UT, and in Pocatello, ID, and Ely, NV. The system is part of VISN 19 and serves a veteran population of 171,851 throughout most of Utah and parts of Idaho and Nevada. Programs. The system provides primary and tertiary care in the areas of medicine, surgery, psychiatry, physical medicine and rehabilitation, neurology, oncology, dentistry, geriatrics, and extended care. It has 121 hospital beds and no nursing home beds. Affiliations and Research. The system is affiliated with the University of Utah and provides training for 123 residents, as well as other disciplines, including dentistry, pharmacy, social work, psychology, occupational and physical rehabilitation, audiology, physician assistant, dietetics, and podiatry. In fiscal year (FY) 2007, the system research program had 270 projects and a budget of $11 million. Important areas of research include geriatrics, mental health, nephrology, neuroimmunology, dermatology, infectious diseases, cardiovascular disease, audiology/speech therapy, and bone and joint diseases. Resources. In FY 2007, medical care expenditures totaled $258 million. The FY 2008 medical care budget is $280 million. FY 2007 staffing was 1,251 full-time employee equivalents (FTE), including 89 physician and 359 nursing FTE. Workload. In FY 2007, the system treated 40,727 unique patients and provided 32,512 inpatient days in the hospital. The inpatient care workload totaled 5,380 discharges, and the average daily census was 90. Outpatient workload totaled 415,379 visits. VA Office of Inspector General 1 Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, UT Objectives and Objectives. CAP reviews are one element of the OIG’s efforts to ensure that our Nation’s veterans receive high Scope quality VA health care services. The objectives of the CAP review are to: • Conduct recurring evaluations of selected health care facility operations, focusing on patient care administration and QM. • Provide fraud and integrity awareness training to increase employee understanding of the potential for program fraud and the requirement to refer suspected criminal activity to the OIG. Scope. We reviewed selected clinical and administrative activities to evaluate the effectiveness of patient care administration and QM. Patient care administration is the process of planning and delivering patient care. QM is the process of monitoring the quality of care to identify and correct harmful and potentially harmful practices and conditions. In performing the review, we inspected work areas; interviewed managers and employees; and reviewed clinical and administrative records. The review covered the following five activities: • Business Rules for Veterans Health Information Systems. • EOC. • Pharmacy Operations. • QM. • SHEP. The review covered system operations for FY 2007 and FY 2008 through March 28, 2008, and was done in accordance with OIG standard operating procedures for CAP reviews. We also followed up on selected recommendations from our prior CAP review of the system (Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, Utah, Report No. 05-01248-170, July 8, 2005). The system had corrected all findings related to health care from our prior CAP review. During this review, we also presented fraud and integrity awareness briefings for 234 employees. These briefings VA Office of Inspector General 2 Combined Assessment Program Review of the VA Salt Lake City Health Care System, Salt Lake City, UT covered procedures for reporting suspected criminal activity to the